6.0 HOME HEALTH SERVICE QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM (QAPI)

Transcription

1 6.0 HOME HEALTH SERVICE QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM (QAPI) EFFECTIVE DATE This manual was developed to set forth the overall home health service quality assessment and performance improvement (QAPI) policies of (Agency). This manual shall be reviewed and revised as necessary, at least once a year. This manual shall be available at all times for review by staff, clients and their designated representatives, and potential applicants for home care services. The effective date of this manual shall be All policies and procedures in this manual were reviewed and approved by: Administrator Signature: Date: Page of 65

2 ANNUAL REVIEW Date: Signature/Title: Page of 65

3 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM TABLE OF CONTENTS 6.0 HOME HEALTH SERVICE QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM (QAPI) SCOPE OF SERVICES OBJECTIVES OF QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM ACTIVITIES FOR MONITORING AND EVALUATION RESPONSIBILITY COMMITTEE RESPONSIBILITIES QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT INITIATIVES QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PHILOSOPHY RESOLUTION OF IDENTIFIED/POTENTIAL PROBLEMS ACTIONS FOR PROBLEM RESOLUTION AND IMPROVEMENT OF CARE CONFIDENTIALITY COLLECTION AND ORGANIZATION OF DATA EVALUATION OF FINDINGS AND IMPROVING PERFORMANCE ASSESSMENT OF EFFECTIVENESS OF ACTIONS ACTION PLAN ASSESSING EFFECTIVENESS REPORTING OF INFORMATION QUALITY CONTROL IMPROVEMENT SCHEDULE/TIMETABLE CASE CONFERENCES CONTINUING REVIEW CLINICAL RECORD REVIEW RECORD REVIEW PROCEDURES PEER REVIEW ROLE OF THE QUALITY IMPROVEMENT TEAM IN INFECTION CONTROL RISK MANAGEMENT ANNUAL PROGRAM EVALUATION CUSTOMER SATISFACTION SURVEY QUALITY IMPROVEMENT INDICATORS Page of 65

4 ASPECT OF CARE, INDICATOR, THRESHOLD ASPECT OF CARE, INDICATOR, THRESHOLD ASPECT OF CARE, INDICATOR, THRESHOLD ASPECT OF CARE, INDICATOR, THRESHOLD ASPECT OF CARE, INDICATOR, THRESHOLD ASPECT OF CARE, INDICATOR, THRESHOLD ASPECT OF CARE, INDICATOR, THRESHOLD ASPECT OF CARE, INDICATOR, THRESHOLD ASPECT OF CARE, INDICATOR, THRESHOLD ASPECT OF CARE, INDICATOR, THRESHOLD ASPECT OF CARE, INDICATOR, THRESHOLD ASPECT OF CARE, INDICATOR, THRESHOLD ASPECTS OF CARE, INDICATOR, THRESHOLD ASPECT OF CARE, INDICATOR, THRESHOLD ASPECT OF CARE, INDICATOR, THRESHOLD ASPECTS OF CARE, INDICATOR, THRESHOLD ADDENDUMS QAPI Worksheet DATA COLLECTION TOOL APPLICANT HIRE LOG EMPLOYEE INSERVICE LOG CLIENT INFECTION CONTROL LOG EMPLOYEE INFECTION CONTROL LOG CLIENT HOSPITALIZATION RECORD ON-CALL LOG CLIENT ADVERSE EVENT/INCIDENT / OCCURRENCE LOG COMPLAINT LOG Page of 65

5 6.1 SCOPE OF SERVICES POLICY: It is the policy of (Agency) to implement and maintain a Quality Assessment and Performance Improvement (QAPI) Program. This program is designed to have a method of objectivity and systematically monitor and evaluate the quality and appropriateness of client care. It also demonstrates the Agency s commitment to continually provide quality health care. None of the information, interviews, reports, statements, memoranda and recommendations produced during or resulting from the agency s quality improvement program may be admissible as neither evidenced nor be discoverable in any action of any kind in any court, as provided in Article VIII, Part 21 of the Code of Civil Procedure (Medical Studies). The goal of our Agency is to continuously improve the quality of services rendered. The responsibility of the QAPI Committee will be to assist in carrying out the objectives and activities of monitoring and evaluating as identified in the QAPI Plan. The Agency s QAPI program consists of but is not limited to the following: 1. Reviewing current standards of practice 2. Reviewing the Agency s processes 3. Client care 4. Infection control 5. Admission 6. discharge 7. Program/staff performance assessment activities 8. Staff recruitment, training, orientation and continuing education programs 9. Case conferences 10. Management meetings 11. Ongoing review of clinical records 12. Clinical staff peer review activities 13. Review of records requested by utilization/record review 14. High volume services, conditions, or diagnoses 15. Evaluation of systems designed to support clinical operations 16. Compliance with clinical practice standards and recognized professional standards 17. Program evaluations based upon measurable objectives, client outcomes and cost effectiveness 18. Management systems that support infection control functions 19. Client satisfaction assessment 20. Quality control activities 21. Annual program evaluation 22. Orientation/training program Page of 65

6 23. Continuing education 24. Performance appraisals 25. Reprioritization of performance activity Page of 65

7 6.2 OBJECTIVES OF QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM 1. To administer and coordinate the Agency s QAPI program which is designed to ensure all quality improvement activities are implemented. 2. To evaluate the delivery of care to clients. 3. To evaluate the processes of service delivery. 4. To provide and validate comprehensive optimal level of safe and effective care/services at reasonable cost. 5. To improve access to community services. 6. To evaluate the appropriateness and outcome of care provided by staff/contract personnel. 7. To monitor and ascertain compliance with Agency policies, procedures, processes, accreditation standards and state and federal regulation. 8. To identify problems, establish a plan and take action to resolve, reprioritize if necessary and evaluate results. 9. To evaluate staff performance, delivery of care, documentation and client outcomes and the Agency s mechanism for addressing them. 10. To evaluate client and staff education. 11. To determine client and physician satisfaction of rendered services. 12. To identify opportunities to improve client care using ongoing collection and screening and evaluating information about the outcome of customer satisfaction surveys. 13. To minimize risk exposure to staff and/or Agency. 14. To oversee the effectiveness of the program and detection of trends, patterns of performance or potential problems that may affect different areas of the organization. 15. To develop effective information systems to communicate quality assessment and improvement activity outcomes to Agency staff and committees. 16. To ensure client and staff confidentiality throughout the quality assessment and improvement process. 17. To evaluate the scope, organization and effectiveness of the quality improvement program ensuring that actions taken are within the mission and goals of the Agency. 18. To identify the need for revisions in client care services, processes, policies and procedures. 19. To identify the extent to which the Agency program is adequate, effective and efficient in the use of all manpower and financial resources. Page of 65

8 6.3 ACTIVITIES FOR MONITORING AND EVALUATION Care or services monitored will include, but are not limited to: 1. Services/care that occur on a high frequency volume 2. Evaluation of systems designed to support operations 3. Compliance with practice standards and recognized professional standards 4. Evaluations based on measurable objectives, client outcomes and cost effectiveness 5. Services/care that present a potential for risk of serious consequences 6. Services/care that have shown problem-prone tendencies 7. Routine collection of information covering all aspects of care. Individual items/aspects of care for monitoring, along with appropriate indicators, thresholds, data collection methodology and evaluation tools will be developed on an on- going basis to accommodate need. This will be developed by the QAPI Committee and presented in standardized format. Client/client outcome program objectives identify the following: 1. The group of clients/clients who are the recipients of service 2. The expected behavior or result of service 3. Time frame for expected results 4. Specified percentage of the client group that is realistically expected to demonstrate results within the expected time frame. Page of 65

9 6.4 RESPONSIBILITY The responsibility of the QAPI Committee is to carry out the stated objectives and activities of monitoring and evaluating as identified in the QAPI Plan. The Board of Directors will assume responsibility for creating and supporting the QAPI program. The Administrator is responsible for assuring implementation and maintenance. A quarterly report of QAPI findings and actions will be presented to the Board of Directors. The Administrator is responsible for assuring implementation and maintenance. This will be accomplished in cooperation with managerial staff and the QAPI Committee. The Administrator is responsible for the QAPI program. A QAPI Committee, consisting of the Administrator, the Administrator and a representative of the scope of practices, will assist with the operation of the QAPI program on an on-going basis. The data will be reviewed by the Administrator and a written report will be submitted to the Administrator, Board of Directors and Board of Directors. Page of 65

10 6.5 COMMITTEE RESPONSIBILITIES The Committee will: 1. Develop a QAPI program covering all aspects of care for approval by the CEO and Board of Directors. 2. Identify and review aspects of care. 3. Design tools for implementation, monitoring and evaluation. 4. Develop Indicators, Criteria and Thresholds. 5. Review standards of practice and compare that with Agency s current processes, policies and procedure. 6. Identify problems or potential problems. 7. In response to identified problems a. Evaluate the process that failed or has the potential to fail b. Identify the areas of the process that coincide with acceptable standards of practice and those that do not c. Develop a plan to change the cause of the problem or the potential problem d. Test the plan with a pilot program that will be at least two visits i. Test visits may be two visits with the same client ii. Test visits may be one visit with two clients e. Evaluate the results of the change f. Propose policy and procedure changes to the PAC. 8. Implement and delegate data collection activities and methodologies. 9. Formulate evaluation tools. 10. Analyze and evaluate data from QAPI activities and other related reports from Safety, Infection Control, Clinical Conferences, Utilization Review, Client Satisfaction Questionnaires, Incident Reports, Emergency Disaster Plan, and other available data. The committee will evaluate these items to determine trends. 11. Review all staff assignments and client care provided to ensure that the clinical decision is made with the client s care and welfare in mind and that the clinical decision making is not endangered when incentives are provided to staff. This includes advising and consulting with management regarding quality improvement issues. 12. Review all incident reports, client and physician questionnaires, monitoring and evaluation activities and any other activities deemed appropriate for QAPI review. 13. Report results of QAPI activities to the Board of Directors, CEO/Administrator and field personnel through written reports and staff meetings. 14. Maintain all data regarding QAPI in a confidential manner and ensure the absence of individual client identification reports. 15. Meetings will be held quarterly with additional meetings to be scheduled in response to identified needs. Page of 65

11 6.6 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT INITIATIVES As an Agency seeking to provide the highest quality of care and customer satisfaction, we must effectively design a quality improvement program that systematically measures, assesses and improves the performance of the quality of care and services provided by the agency. The design emphasizes the importance of the Agency affecting its best efforts to create appropriate processes and functions required to achieve improved client health outcomes and customer satisfactions. It ensures the provision of uniform quality care and services throughout the Agency as reflected in the Agency s mission, goals and vision and within the dimensions of quality performance which are defined as follows: 1. Doing the right thing with efficiency and appropriateness relating to the degree to which care and services will achieve the desired or projected outcomes and relevant clinical needs of the client. 2. Doing the right thing with regard to the: a. availability to meet the client s needs b. timeliness of the provision of services at the necessary or most beneficial time for the client c. effectiveness to correctly provide care and services to achieve the desired outcomes for the client d. continuity of services provided with respect to service coordination with clinicians, providers and over time e. safety to clients and others with respect to reduce risk of interventions and environment to the client and others including staff f. efficiency of service with regard to results of care resources used to deliver care g. respect and caring which allows the client or designee to be involved in the care decisions and services to be provided with sensitivity and respect for the client s needs, expectations and individual differences. Page of 65

12 6.7 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PHILOSOPHY The organizational management has developed through its Quality Assessment Performance Improvement Program the following care concepts: 1. Management individually and collectively plays a key role in enabling the Agency to systematically assess and improve performance. 2. The realization that most problems and opportunities for improvement are derived from process weakness, not individual incompetence. 3. Careful coordination of work and collaboration is needed among departments and professional groups. 4. The importance of seeking judgments about quality from clients and others and using such judgment to identify areas for improvement. 5. The need for both systematically improving the performance of functions and maintaining the stability of these functions. Page of 65

13 6.8 RESOLUTION OF IDENTIFIED/POTENTIAL PROBLEMS Communication of problems plans for resolutions, and evaluation of results will be the responsibility of the Administrator. The staff will have the responsibility to communicate findings and if necessary recommend corrective action. Page of 65

14 6.9 ACTIONS FOR PROBLEM RESOLUTION AND IMPROVEMENT OF CARE Actions may involve the following but are not limited to: 1. In-service Education 2. Change in Personnel 3. Policy or procedural changes with approval of Board of Directors. Page of 65

15 6.10 CONFIDENTIALITY All persons participating in any aspect of the QAPI process will adhere to the Agency s confidentiality policies. All studies are performed in a manner that assures confidentiality for clients and caregivers and Agency staff. To assure confidentiality: 1. Codes will be utilized to identify individuals. 2. Protection of data will be the responsibility of the Administrator or his/her designee. 3. QAPI committee members, along with all staff having access to records/information will be informed of the Agency confidentiality policy. 4. Identifiable client information is maintained by the Administrator in secure files. Page of 65

16 6.11 COLLECTION AND ORGANIZATION OF DATA Data collection is a uniform and systematic process that ensures that only relevant, useful and necessary data is collected. It includes measuring functions, processes and outcomes that affect the dimensions of care, client and family involvement in care and customer quality and satisfaction. In addition, the Agency will measure the following functions: 1. Current accepted standards of practice 2. Rights, responsibilities and ethics 3. Assessment of clients 4. Continuum of care 5. Care, treatment and service 6. Education 7. Leadership 8. Management of information 9. Management of human resources 10. Management of the care environment 11. Surveillance, prevention and control of infection 12. Improving organizational performance 13. Major variances in allocated budgets 14. Evaluating incentive provided by the Agency Data will be collected from various sources to be monitored. Sources of data collection will be, but are not limited to: 1. Case conferences 2. Audit reports 3. Ongoing chart review and clinical record/utilization review 4. High volume services, conditions or diagnoses 5. Problems identified 6. Clinical staff competency testing program 7. Employee files 8. Incident reports 9. Satisfaction surveys 10. Supervisory review or observations 11. Management systems that support infection control functions 12. Management meetings 13. Risk management program 14. Quality control activities 15. Annual program evaluation 16. Financial operation Page of 65

17 17. Reprioritization of performance activities Sample size, data source, and methodology will also be identified in standardized format as mentioned above. Collected data will be recorded on standardized work sheets and reports. Data collected will be used by the Agency to: 1. Design, test and assess new processes 2. Assess dimensions of performance 3. Measure the level of performance and stability of existing processes 4. Identify areas of improvement in existing processes and whether or not the results of changes improved the processes. The collection of data will use a scientific approach for collecting the information and use statistical control methods for evaluation and comparison of findings. Time frames for data collection and statistical techniques for analysis are determined by the QAPI committee to ensure that appropriate outcomes for client care, Agency functions, process and quality are appropriate and customer satisfaction are all continuously achieved. Organizational logs will be maintained to track and evaluate the following: 1. Re-hospitalizations 2. Infections a. use of antibiotics by clients/clients b. staff infections necessitating loss of time at work 3. Staff on call log 4. Client/client grievances 5. Staff grievances, incidences and occurrences, medical devise reporting 6. In-service education 7. Complaints 8. Safety hazards and misuse of equipment Page of 65

18 6.12 EVALUATION OF FINDINGS AND IMPROVING PERFORMANCE The focus of quality improvement activities is to identify opportunities for improved performance by the Agency. The improvement of performance can be accomplished by: 1. Redesigning a process which will lead to improved processes and performance by the Agency 2. Designing a new process leading to innovation 3. Improvement strategy may be implemented system wide or may encompass only a limited area of concern or staff performance. The Board of Directors, management, and others involved with clients including physicians and staff participate in evaluating the information collected and improving the process and performance of the Agency. The design is reviewed and re- evaluated based upon the Agency mission, goals and visions. The information is presented quarterly at the QAPI meetings. At this time, identified problems are analyzed. Page of 65

19 6.13 ASSESSMENT OF EFFECTIVENESS OF ACTIONS Ongoing monitoring and evaluation of each indicator and analysis of logs will be performed to ensure effective resolution. If the problem is not resolved or improvement is not apparent, the actions taken will be reassessed and further changes will be formulated. Areas to be considered in prioritizing a process for improvement will include, but not be limited to: 1. The degree to which the process, function of service is consistent with the Agency s mission, vision and philosophy. 2. Concerns related to clients health and safety. 3. Concerns of the Agency s customers and staff relating to process, design, function or service. 4. Impressions of experts. 5. Findings in comparative data bases. The listing of priorities will provide a basic set of performance expectations that can be measured, assessed and improved over time. Once data has been turned into information by summarizing and organizing it, the information is evaluated. Page of 65

20 6.14 ACTION PLAN 1. Once the situation is identified, whether actual or potential, the Agency is ready to take action. In order to be effective, any actions to be taken are communicated to the appropriate staff and management. They include: a. What action is to be taken based on the problems identified and their causes, scope and severity b. Who is responsible for making changes c. The time table for implementing the pilot program d. The time table for evaluating the results of the actions to be taken. 2. Types of actions that may need to be taken: a. Actions for systems problems may include: i. Changes in communication channels ii. Changes in organizational structures and processes. iii. Adjustments to staffing and changes in equipment, facility design or chart forms b. For problems involving understanding, the actions taken may include: i. Continuing education ii. In-service education iii. Attending seminars. iv. Consultation with peers c. Behavior problems may require the following: i. Counseling employees ii. Changes in individual assignments or disciplinary action against one or more employees. iii. Required corrective actions are recorded in the individual s personnel file. 3. Systematic approach to testing: For each process assessed, it will be determined whether opportunities to improve performance exist. When multiple opportunities exist, improvement opportunities will be prioritized. A systematic approach will be used, including the following: a. Potential improvement expected b. Strategies for implementing the improvement change c. Testing the proposed change with a pilot program d. Assessing the improvement that occurred e. Redesign of strategies as necessary. f. System-wide implementation 4. Additionally, the basis for the priorities chosen are those that best assist in: a. Achieving the goals of the Agency s strategic plan and mission statement b. Resolving problems related to the needs of high volume, high risk or problem prone clients Page of 65

21 c. Meeting the stated purposes of the functions and indicators being studied d. Meeting the needs of employees and the Agency 5. Design of improvement approach: a. The design of the improvement approach will consider the following: i. The dimensions of performance that will be most affected by the change ii. Whether there is an interaction between dimensions that are being considered iii. Identification of what performance is expected from the improved process iv. Identification of who needs to be involved in the improvement activity. b. The person(s) responsible for implementing the actions is to determine the appropriate actions to take. Action is taken and the results are forwarded to the Administrator. c. The actions are to be directed toward the identified root causes with an eye toward overall improvement in quality of client services provided. d. If the data are of significant import and the findings are negative, the Administrator must prioritize the overall QAPI activities and decide if the situation warrants more intense investigation, given overall priorities. A more intensive review may include: i. Collecting additional information ii. Peer review iii. Use of additional statistical techniques to examine the data from other aspects. e. The goal of these activities is to understand the reasons why some of the data are significantly outside the expected norm. Steps are taken to bring all cases in the function or process being monitored to the desired range. 6. Written Plan: The action plan will be delineated in writing specifying the actions, date of completion and person responsible. 7. Problem solving for each problem will include: a. Recommended actions and responsible person for each b. Time frame for implementation c. Expected outcome d. Monitoring activities i. Need for ongoing monitoring ii. Documentation of problem solving activity Page of 65

22 6.15 ASSESSING EFFECTIVENESS The Committee and Administrator evaluate the effectiveness of actions taken. Assessing the effectiveness of the actions taken can include: 1. Continuing to monitor the indicator for additional monitoring periods 2. Using additional monitoring techniques 3. Initiating special or ongoing monitoring rather than sampling. Changes may be piloted on a small scale before they are implemented Agency wide. Page of 65

23 6.16 REPORTING OF INFORMATION The Administrator or other designated staff will document committee minutes and maintain all records provided by the committee for established studies. He/she is responsible for communicating the conclusions, recommendations, actions and follow-up to appropriate individuals and management. The mechanism for communicating relevant information is delineated in writing and includes: 1. Who will receive the information? 2. Type of information to be shared? 3. How information will be shared? 4. Frequency of information sharing? The committee will meet quarterly. Minutes of the meetings will be given to the Administrator on a quarterly basis. The Professional Advisory Board will receive reports at each meeting. Page of 65

24 6.17 QUALITY CONTROL Information regarding the results of all quality control activities will be reported to the Administrator who will review the results and use the findings and conclusions of the review to take appropriate action when necessary. Quality control activities apply to monitoring equipment used in providing care. The supervisor assesses the condition of equipment used during routine supervisory visits. The Administrator teaches staff to report equipment problems to him/her as they occur. Problems are immediately reported to the entity who provided the equipment and are documented in the Hazardous Medical Device log as well as in the client s record. Examples of data collection can be documented in management meeting minutes, committee reports, client records, and quality control collection documents. Page of 65

25 6.18 IMPROVEMENT SCHEDULE/TIMETABLE In order to successfully administer the QAPI program, a schedule of QAPI activities is developed. Scheduling allows measurement/evaluation activities, meetings and the production of reports to be staggered. Staggering allows the distribution of these activities over time so that no one month is unduly busy due to QAPI activities. Using this timetable the DON, along with the Administrator, produces a schedule for when: 1. Each of the indicators selected will be measured, tabulated, and summarized monthly 2. Needed meetings will occur, quarterly and as needed 3. Reports will be prepared, quarterly 4. The plan will be reviewed/revised once yearly and as needed 5. Any other activities are to occur. Page of 65

26 6.19 CASE CONFERENCES The purpose of case conferences is to: 1. Determine the adequacy of the plan of treatment and appropriateness of continuation of care 2. Assure coordination of services in client-goal directed activity on the part of each home care staff member 3. Evaluate client progress and plans for future care 4. Provide assistance to team members having difficulty planning care for specific problem cases 5. Refer cases which require further study to the clinical record review committee. Case conferences shall be held regularly to review problem cases and to review the plan of treatment for appropriateness and feasibility of continued services. Such conferences shall be documented separately or in the clinical record and should be held for each client at the time of admission, prior to the date the plan of treatment is due for the review (every 60 days or more often) and prior to discharge. However, if a problem arises, a case-specific conference would be indicated. All staff members participating in the client s care should have input at this conference. For personnel participating in the client s care but unable to attend the conference, a telephone conference could be established. Documentation of the conference shall be the responsibility of the supervisor, or other professional as instructed by the supervisor. The documentation shall include a summary of progress, assessment of the need for continued care, plans, and discharge tools. For clients receiving equipment, the appropriateness and operation of the equipment will be considered in the review as indicated. All staff delivering client care services is encouraged to have at least weekly contact with their supervisor. This contact can be in the form of individual conferences held within the office, telephone conferences or group case conferences. Any conference related to an individual client may be documented as a case conference. Page of 65

27 6.20 CONTINUING REVIEW A periodic review of client progress is a method of continuous audit services rendered to the client. A summary regarding the client s progress is prepared by all professional disciplines participating in the client s care and is submitted to the physician at least every 60 days. The review will usually occur in conjunction with a recertification process. A copy of the summary is maintained in the clinical record. The continuing review of client progress and case conferences assists the Agency in meeting client care objectives by: 1. Evaluating the client s eligibility for home health care 2. Reviewing the performance of client care as ordered by the physician 3. Assessing the appropriate use of personnel and the services provided 4. Planning and/or evaluating the involvement of family members in the client care plan 5. Assessing the effect that the services have had upon the client, including discharge planning 6. Planning and/or evaluating the future plans for the client 7. Determining the appropriateness of continuation of care 8. Reviewing the written progress report that is sent to the client s physician 9. Providing learning experiences for staff development 10. Identifying, evaluating and updating information for program development Page of 65

28 6.21 CLINICAL RECORD REVIEW Clinical record review is a method of systematic evaluation of the documentation in the clinical record. Its purpose is to ensure that: 1. Service is provided according to the treatment plan. 2. Professional and client care policies are followed in giving care. 3. Needs of the client are being met both quantitatively and qualitatively. 4. Continuity of care is provided within the Agency, among agencies and with physicians. 5. Components of services that are not available within the Agency and/or community are identified. 6. Services are provided economically and effectively to promote, achieve and maintain the individual s optimum state of health and function. 7. All clinical records will be reviewed continuously for each certification period that the clients receive services. The clinical record review committee is appointed by the Agency administration with approval of the Board of Directors. The Director of Quality Assurance shall function as the chairperson and shall report to the Agency administration the findings and recommendations. The committee is interdisciplinary and composed of members including the professional disciplines represented by the Agency and at least one member who is not an Agency employee. The committee shall meet at least quarterly and review a sampling of active and closed cases to assure that established policies are followed in providing services. The objective of the sampling is to obtain a valid picture of all Agency services. The size of the sample will vary depending on the number of clients serviced, but must constitute a minimum of 10% of the annual unduplicated client admissions of clients receiving each service offered during the previous year. If less than one hundred clients are serviced, a minimum of 5 records must be reviewed quarterly by the committee. The records shall be selected by random sample from the active and inactive files and will include representation of all disciplines providing care, diagnostic categories, lengths of stay and discharge.. Problem cases are presented to the committee as needed. Audited records shall carry some notation that they have been audited and the date. These records will not be selected for audit in the subsequent quarter unless specifically requested by committee members. The frequency of the clinical record review committee meetings may increase from quarterly to more often if the volume of records to be reviewed increases. The QAPI Manager or the Administrator will review, record the proceedings and prepare a summary of findings to be used by the Agency and reviewed by the Advisory Committee. Page of 65

29 6.22 RECORD REVIEW PROCEDURES Each committee member will review the records assigned to him/her by the chairman and will review the records using the Agency s standard review form. A committee member cannot review his/her own records. Following the individual record review, a summary of the findings will be presented to the committee by the reviewer. The chairperson shall prepare a report of the committee findings and recommendations. The chairman of the committee presents the committee report with findings and recommendations to the Board of Directors. The Agency is responsible for utilizing the findings and recommendations of the committee in order to take appropriate action in Agency planning and staff development to improve the quality of service and enhance home health services in the community. The clinical record review committee reports are utilized in the Agency s annual evaluation process. Page of 65

30 6.23 PEER REVIEW An Agency participating in peer review shall, in addition to quarterly record review, conduct a clinical record audit in accordance with Agency procedures on each record requested by peer review for clients discharged from a hospital and admitted to the Agency and subsequently re-admitted to the hospital within 30 days. All professional disciplines must comply with their respective professional practice acts or title acts relation reporting and peer review. The coordinator will present the findings and recommendations to the Administrator. All professional disciplines must comply with their respective professional practice acts or title acts relating to reporting and peer review Peer review records may also be reviewed by the clinical record review committee. The results and recommendations will be presented to the Board of Directors for their review and action. Page of 65

31 6.24 ROLE OF THE QUALITY IMPROVEMENT TEAM IN INFECTION CONTROL The Quality Improvement Committee will provide oversight and guidance for infectious control activities within the Agency. In this role, the Quality Improvement Team will: 1. Support the implementation of infection control policies and procedures within the Agency 2. Support surveillance activities 3. Review and analyze surveillance data at least quarterly 4. Identify, implement and support additional surveillance activities as appropriate for the population served 5. Promptly notify proper authorities of reportable control and medical device instruments 6. Support annual mandatory infection control/medical device reporting education 7. Identify and provide at least one additional annual infection control continuing education program based upon the needs of the Agency, staff and client/client population served 8. Identify and support at least one focused project per year for the reduction of risk of infection in clients/clients and Agency staff. Policies and procedures for infection control will be developed and approved at the corporate level. Any issues and areas needing policy and/or procedure development or revision should be brought to the attention of the corporate Board of Directors. The QAPI Director or the Administrator is responsible for assuring that local infection control policies and procedures are in compliance with local or state regulations and laws. Page of 65

32 6.25 RISK MANAGEMENT Risk management is designed to identify areas of Agency operations which pose a potential risk to the Agency, its employees and clients. Management systems are in place to support, coordinate and implement risk management and infection control functions. The staff member assigned to oversee risk management shall seek to identify the occurrence of any event which could pose a risk. Potential risks shall signal the need for revisions to company policies, procedures and operating practices and for education, training and supervision of staff. The steps to evaluating a risk include: 1. Identification 2. Investigation of the casual factors and review of company policies, procedures, operating practices and professional standards of practice 3. Development and implementation of corrective actions 4. Evaluation and monitoring the response and effect of corrective action. Areas of potential risk include but are not limited to a. Deviations from company policies and procedures b. Deviation of clinical/professional practice standards c. Accidents/incidents/unusual occurrences d. Safety violations and/or hazards e. Equipment failure/misuse f. Occupational exposure 2. Consumer complaints 3. Employee grievances/conflict resolution 4. Infection control 5. Personnel management 6. Other data as required by local, state, Federal regulatory bodies and/or funding sources. Information management and leadership functions support the requirements of the risk management and infection control functions for aggregation, comparison of knowledge based data, knowledge of staff to interpret findings, and establish a plan for monitoring and evaluating the effect of the corrective action taken to reduce risk. The responsibility of management is to assure these activities occur. Page of 65

33 6.26 ANNUAL PROGRAM EVALUATION The Agency, through the Board of Directors, Advisory Committee and Agency staff, shall annually evaluate the extent to which the Agency s program is appropriate, adequate, effective and efficient. The Agency may also contract with a qualified organization to perform the evaluation. The scope of the review shall encompass the following client care information including: 1. Policies and procedures. 2. Organizational structure and system. 3. Achievement of goals. 4. Demographics of clients serviced. 5. Measurable client outcomes. 6. Programs, including utilization and quality of services and products, appropriateness and adequacy. 7. Effectiveness and efficiency (including information about referrals not accepted). 8. Human resources. 9. Safety practices. 10. Risk management. 11. Financial resources and billing practices. 12. Information systems. 13. Performance improvement findings. 14. Number of clients not accepted, with reasons. 15. Total staff days for each service offered Active number of clients. 17. Average number of visits per discharged client. 18. Clinical record review and quality improvement review findings. 19. Results of questionnaires to active and discharged clients and physicians. 20. Review of personnel records, by category. 21. Review of conformance with personnel policies. 22. Personnel qualifications. 23. Turnover of personnel, by category. 24. Participation in both in-service and continuing education programs. 25. Review of administrative and financial activities including: a. Administrative policies and procedures b. Budget c. Cost reports and financial statements. The review committee shall use available instruments and criteria to evaluate the performance of the Agency in meeting its mission and goals. The written evaluation will be prepared and presented to the entire Advisory Committee which will review the committee s findings and prepare Page of 65

34 recommendations. The written recommendations shall be submitted to the Board of Directors which shall take action on all recommendations submitted by the Advisory Committee. The Administrator shall be responsible for implementing the recommendations of the Board of Directors and shall periodically report to the Board of Directors and the Advisory Committee regarding this process. Statistics gathered as a result of the annual review may serve as planning tools for the Agency administrative staff to determine growth patterns, staffing needs, and client care needs within the Agency. Annual evaluation reports are retained for five years or according to state requirements, whichever is longer. Page of 65

35 6.27 CUSTOMER SATISFACTION SURVEY Page of 65

36 CUSTOMER SATISFACTION SURVEY (CONTINUED) Page of 65

37 6.28 QUALITY IMPROVEMENT INDICATORS Page of 65

38 Aspect Clients admitted to service Indicator QUALITY IMPROVEMENT ASPECT OF CARE, INDICATOR, THRESHOLD A client shall have an admission assessment initiated within 48 hours of referral acceptance by the Agency unless otherwise specified 1. Initial assessment 2. A standard Agency assessment form shall be completed 3. Admission to service shall be according to Agency Admission Criteria policy Threshold 90% Sample Random a minimum of 10% referrals Methodology Review of charts by the Administrator or designee Responsibility Results will be submitted to the Administrator or his/her designee whose responsibility it shall be to channel any identified problems to the appropriate staff for resolution and follow-up. Page of 65

39 Aspect Client Teaching Indicator QUALITY IMPROVEMENT ASPECT OF CARE, INDICATOR, THRESHOLD Clients are taught what their diagnosis means and any modifications they need to make in their lifestyle. 1. Record documentation shall indicate the teaching done and the response to teaching by the client/caregiver. Threshold 90% Sample Random a minimum of 10% of referrals Methodology Review of charts by the Administrator or designee Responsibility Results will be submitted to the Administrator or his/her designee whose responsibility it shall be to channel any identified problems to the appropriate staff for resolution and follow-up. Page of 65

40 Aspect Annual Performance Evaluation Indicator QUALITY IMPROVEMENT ASPECT OF CARE, INDICATOR, THRESHOLD The field staff demonstrate competency in all job functions as measured by the results of their annual performance evaluation. 1. Personnel files shall be reviewed to determine whether a performance evaluation has been performed. 2. The performance evaluation is conducted at three months and yearly thereafter. 3. Competency evaluations are performed as indicated. Threshold 95% Sample Random a minimum of 10% of referrals Methodology Review of charts by the Administrator or designee Responsibility Results will be submitted to the Administrator or his/her designee whose responsibility it shall be to channel any identified problems to the appropriate staff for resolution and follow-up. Page of 65

41 Aspect Hand Washing Technique Indicator QUALITY IMPROVEMENT ASPECT OF CARE, INDICATOR, THRESHOLD Aides demonstrate proficiency in hand washing technique. Competency performance is documented in each worker s personnel file. Threshold 90% Sample Random a minimum of 10% of referrals Methodology Review of charts by the Administrator or designee Responsibility Results will be submitted to the Administrator or his/her designee whose responsibility it shall be to channel any identified problems to the appropriate staff for resolution and follow-u Page of 65

42 Aspect Client Satisfaction Indicator QUALITY IMPROVEMENT ASPECT OF CARE, INDICATOR, THRESHOLD Clients receiving Agency services express satisfaction with the services received as evidenced by the results of a client survey that documents whether: 1. Clients have been told of the Agency s 24-hour availability 2. Clients are satisfied with the care received 3. Clients are able to reach the Agency when they need to 4. Clients requests are addressed immediately 5. Clients would refer friends and relatives to the Agency 6. All staff are courteous and helpful Threshold 90% Sample Random a minimum of 10% of referrals Methodology Client satisfaction and telephone surveys Responsibility Results will be submitted to the Administrator or his/her designee whose responsibility it shall be to channel any identified problems to the appropriate staff for resolution and follow-up. Page of 65

43 Aspect Client Rights Indicator QUALITY IMPROVEMENT ASPECT OF CARE, INDICATOR, THRESHOLD Clients can verbalize their rights as evidenced by their response to the following questions: 1. Are you being treated with dignity? 2. Do you know the name of the Agency contact person? 3. Did someone explain the care you are going to receive? 4. Do you know how to report a complaint? Threshold 90% Sample Random a minimum of 10% of referrals Methodology Chart documentation and telephone survey Responsibility Results will be submitted to the Administrator or his/her designee whose responsibility it shall be to channel any identified problems to the appropriate staff for resolution and follow-up. Page of 65

44 Aspect Home Health Aide Plan of Care Indicator QUALITY IMPROVEMENT ASPECT OF CARE, INDICATOR, THRESHOLD A client receiving home health aide services shall have a plan of care which is updated at least every 60 days. 1. Updating shall be done by the Administrator or designee and shall reflect the client s current care needs. 2. Review of care plan at least every 60 days shall be documented on the care plan in the home as well as the original contained on the active chart. Threshold 90% Sample Random a minimum of 10% of charts. Charts reviewed will list home health aide services as ordered by the physician. Methodology Review of charts on a quarterly basis or more frequently if necessary. Responsibility Results will be submitted to the Administrator or his/her designee whose responsibility it shall be to channel any identified problems to the appropriate supervisory staff for resolution and follow-up. Page of 65

45 Aspect Checklist for home safety Indicator QUALITY IMPROVEMENT ASPECT OF CARE, INDICATOR, THRESHOLD A client receiving home health services shall have a checklist for home safety. 1. Instructions on home safety shall be taught to the client and/or caregiver and documented in the client s record. 2. Review of the home safety checklist should be documented in accordance with the client s environment. Threshold 90% Sample Random, a minimum of 10% of charts Methodology Review of chart by Administrator or designee on a quarterly basis or more frequently if necessary Responsibility Results will be submitted to the Administrator or his/her designee whose responsibility it shall be to channel any identified problems to the appropriate supervisory staff for resolution and follow-up. Page of 65

46 Aspect Dietary and Hydration compliance Indicator QUALITY IMPROVEMENT ASPECT OF CARE, INDICATOR, THRESHOLD A client record shall contain documentation of the client s understanding of dietary and hydration compliance by the fourth week of service. 1. The client will understand and verbalize dietary requirements and restrictions and be in compliance with same. 2. The client will understand and verbalize hydration requirements and restrictions and be in compliance with same. Threshold 90% Sample Random minimum of 10% of charts as well as 100% of identified clients hospitalizations during service Methodology Review of charts by the Administrator or designee on a quarterly basis or more frequently if necessary Page of 65

47 Aspect Assessment of the client s suicidal status Indicator QUALITY IMPROVEMENT ASPECT OF CARE, INDICATOR, THRESHOLD Each psychiatric client will receive a suicidal assessment on the initial visit and a suicidal assessment form will be completed. All clients with active/passive suicidal ideations are assessed and evaluated for the degree of suicidal lethality during each visit and this information is documented appropriately. 1. The client record will reflect that the client is safe. 2. If the client is determined unsafe, the progress note will show that the MD/Psychologist was notified and crisis intervention procedures were followed. Threshold 90% Sample Random a minimum of 10% of charts as well as 100% of identified clients hospitalizations during service Methodology Review of charts by the Administrator or designee on a quarterly basis or more frequently if necessary Page of 65

48 Aspect Missed Visit Indicator QUALITY IMPROVEMENT ASPECT OF CARE, INDICATOR, THRESHOLD Actual and scheduled home health aide visits will agree. Threshold 90% Sample Random a minimum of 10% of charts as well as 100% of identified clients hospitalizations during service Methodology Review of charts by the Administrator or designee on a quarterly basis or more frequently if necessary Responsibility Results will be submitted to the Administrator whose responsibility it shall be to channel any identified problems to the appropriate supervisory staff for resolution and follow-up. Page of 65

49 Aspect QUALITY IMPROVEMENT ASPECT OF CARE, INDICATOR, THRESHOLD Personnel files document employee qualification, education and experienced criteria Indicator The personnel file will contain a signed job description which describes the qualifications of the position and the expectations of the position. 1. The personnel file will contain documentation of licensure verification upon hiring and at least every two years thereafter. 2. The personnel file will contain a completed application or resume which demonstrates that the employee meets the education and experience requirements of the job 1. description. 2. The personnel file will contain an orientation checklist which demonstrates the completion of the orientation program with the Agency established time frame. 3. The personnel file of the home health aide will contain documentation of adherence to required in-services (12 hours per year). 4. The home health aide personnel file will contain proficiency/competency test results 5. of 75% or higher within five days of hire and yearly thereafter. The employee will not do direct client care until successful completion. 6. The personnel file will contain a completed skills checklist within 5 days of hire. The employee will not do direct client care until successful completion. Threshold 90% Sample Random a minimum of 10% of referrals Methodology All personnel files will undergo an audit at least annually. A written report will be provided to the QAPI Chairperson within one week of completion. Responsibility Results will be submitted to the Administrator or his/her designee whose responsibility it shall be to channel any identified problems to the appropriate staff for resolution and follow-up. Page of 65